What is the standard procedure for performing a vertebroplasty?

Standard Procedure for Vertebroplasty

Vertebroplasty is performed under fluoroscopic guidance with the patient under moderate sedation or general anesthesia, involving percutaneous injection of polymethylmethacrylate (PMMA) cement into a fractured vertebral body through a transpedicular or parapedicular approach to stabilize the fracture and provide pain relief. 1

Pre-Procedure Evaluation

Patient Selection

• Appropriate imaging must be performed to confirm diagnosis and plan the procedure:
  • Initial X-rays to identify compression fractures
  • MRI (preferred) to distinguish between benign osteoporotic and pathological fractures, assess fracture acuity, and identify unhealed fractures 1
  • STIR or T2-weighted sequences with fat saturation are most useful for identifying unhealed fractures 1

Indications

• Symptomatic osteoporotic or cancer-related vertebral compression fractures refractory to medical therapy 1
• Failure of medical therapy defined as:
  • Back pain preventing ambulation or physical therapy despite appropriate analgesia
  • Significant side effects from required analgesic doses
  • Duration of medical therapy of at least 6 weeks 1

Contraindications

• Absolute contraindications:
  • Active systemic infection, particularly spinal infection
  • Uncorrectable bleeding diathesis
  • Insufficient cardiopulmonary health to tolerate sedation/anesthesia
  • Known allergy to PMMA 1
• Relative contraindications:
  • Significant spinal canal stenosis or compressive myelopathy
  • Radiculopathy exceeding local vertebral pain 1

Technical Requirements

• Procedure suite with adequate space for patient monitoring and imaging equipment
• High-quality fluoroscopy (biplane preferred, especially during cement delivery)
• Rapid availability of CT/MRI for potential complications
• Cardiopulmonary resuscitation equipment 1

Procedural Steps

1. Patient Preparation:

   • Confirm patient identity, procedure, site, and consent
   • Have pre-procedural imaging available in the procedure room
   • Monitor vital signs, pulse oximetry, and blood pressure 1
   • Position patient prone on radiolucent table 2

2. Anesthesia:

   • Most procedures performed under local anesthesia with moderate sedation
   • General anesthesia may be used for patients at high risk of airway/respiratory complications or requiring significant pain control 1

3. Approach and Needle Placement:

   • Transpedicular or parapedicular approach under fluoroscopic guidance
   • Sterile preparation and local anesthetic administration
   • Placement of 11-13 gauge needle through pedicle into the anterior third of the vertebral body 2, 3

4. Cement Preparation and Injection:

   • PMMA cement is prepared to achieve proper viscosity
   • Continuous fluoroscopic monitoring during injection to detect potential cement leakage
   • Injection stopped if cement approaches posterior vertebral body wall or leakage is detected 1, 2

5. Post-Procedure Monitoring:

   • Period of bed rest and observation
   • Regular assessment of vital signs and lower limb neurological function
   • Supervised ambulation after appropriate observation period 1

Post-Procedure Care

• Most patients can be discharged same day or after overnight observation
• Near-term follow-up to assess pain and mobility levels
• Counsel patients to report any sudden increase or new back pain (may indicate new fracture) 1

Potential Complications

Major complications occur in less than 1% of osteoporotic fracture cases and less than 5% of neoplastic cases 1. These include:

• Cement leakage (common but usually asymptomatic)
• Nerve or spinal cord injury
• Pulmonary embolism (cement, air, or fat)
• Infection (osteomyelitis, epidural abscess)
• Bleeding (vascular injury, hematoma)
• Fracture (rib, pedicle, or vertebral body)
• Cardiovascular complications
• Pneumothorax (for thoracic levels) 1

Important Considerations

• Cement leakage is common (72% in VERTOS II) but usually asymptomatic 1
• Cement pulmonary emboli occur in approximately 26% of cases but are typically asymptomatic 1
• Secondary fractures occur in approximately 19% of cases within 2 years, similar to conservative management 1
• Cross-sectional imaging should be performed immediately if clinical deterioration occurs 1

By following this standardized approach, vertebroplasty can be performed safely and effectively to reduce pain and improve quality of life in appropriately selected patients with vertebral compression fractures.